The Medicaid Health Homes in the State of Missouri

The Medicaid Health Homes in the State of Missouri

The Medicaid Health Homes in the State of Missouri enable health care provides in the state of Missouri to offer further healthcare services to their patients who subscribe to the Medicaid plan- both children and adults, having particular chronic conditions. A health home is a specific designation under section 2703 of Obamacare (Unützer, Harbin, Schoenbaum & Druss, 2013). Obamacare is also known as the Patient Protection and Affordable Care Act. The health home care model provides coordinated, patient-centered, and whole-person care for all stages and transitions of healthcare, particularly for individuals suffering from chronic illnesses. Eligibility for Health Home requires the enrollees of Medicaid to have two or more chronic conditions. The enrollees also qualify if they have one chronic condition and are at the risk of developing a second condition from hypertension, overweight, heart disease, diabetes, asthma, substance abuse, or mental health problems (Mikkelsen, Cohen & Frankowski, 2014). The research study has three aims at the state level and three other aims across the four regional cases. The first aim at the state level is to determine the program components that worked well individually or in combination to reduce the super-utilization of the emergency department. In responding to this question or objective, there must be an understanding of how the respondents believe they have aided the result. The second aim is determining the implementation methods which have helped in implementing these program components. Thirdly, the study aims at understanding the barriers and facilitators encountered by the program staff in achieving their model aimed at reducing Medicaid ED super utilization.

Findings at State Level

To gather adequate information about the implementation of the program, in-depth, detailed qualitative interviews were conducted via the telephone. Using the IOWA study, a sample of 18 Medicaid homes was used to provide the most diverse group of potential respondents, both in urban and rural settings. The findings of the study were summarized from 11 health homes. The health homes participating in the in-depth telephone interviews represented federally qualified health centers, clinics connected to larger hospital systems, and rural health centers. The interviews were conducted for a period of between 20 and 60 minutes. To allow the health homes to describe their experiences in a detailed fashion, the study designed the questions to be open-ended. The findings presented in this segment are a part of the recorded and transcribed analysis of the study based on the themes related to the implementation.

Findings

The health homes that took part in the study were representative of four federally qualified health centers, two rural health centers, and five clinics connected to the larger hospital systems. The critical informant respondents originated both in remote rural and urban areas. Primary care health homes started at the beginning of 2012 as a component of a continuous or ongoing effort in Missouri aimed at improving health outcomes for people with complicated, manageable chronic diseases through enhanced care coordination and management and the integration of primary care and behavioral health care services. The primary care health home efforts extend the principles or concepts that were developed in the CCIP- Chronic Care Improvement Program that started in 2006. The goals of the program have been skewed towards improving health, minimizing disease complications, and reducing Medicaid costs for people with diseases that are chronic but can be managed. PCHH-Primary Care Health Homes, further work by incorporating prior work supported by the DMH- Missouri Department of Mental Health, MOCMHC-Missouri Coalition of Community Mental Health Centers, and MPCA- Missouri Primary Care Association.

Research studies have shown that about 50 percent of expenditures involving healthcare are attributed to about 5 percent of the population- individuals often called super-utilizers of health care. These groups of people are most commonly the sickest patients, a majority of whom have three or more chronic conditions. In a single year, super-utilizers visit the emergency department countless times.

Patient-Centered Medical Homes

Some health centers and clinics have started the process of advancing to become a patient-centered medical home. Some of theme were already known as a patient-centered medical home before becoming Missouri Medicaid Health Home. The study also established that the NCQA had recognized some of the hospitals and health centers as level three patient-centered medical homes. The respondents of the survey indicated that for health centers and clinics which had not become PCMH yet, significant plans were being put in to ensure this level is achieved (Askelson et al., 2014). Other respondent health centers and clinics did not initiate the process of becoming a patient-centered medical home until the decision was made to become a Missouri Medical Health Home. When looked at from the perspective of clinics that had already been recognized as PCMH, the process of implementing the requirements for the Missouri Medicaid Health Home was more challenging for those health centers that were just starting the process of becoming PCMH (Askelson et al., 2014). While the journey to becoming a National Committee for Quality Assurance-acknowledged and recognized patient-centered medical home is incredibly tricky for several clinics, respondents from the mentioned clinics were not able to readily articulate what the Missouri Medicaid Enterprise would achieve in better supporting the process. After further probing during the questioning and interviews, a small number of clinics were able to identify the particular areas of need where the enterprise could provide help and assistance.

Changes made to become a Missouri Medicaid Home

For most health centers and clinics that were not involved in the process of developing into a patient-centered medical home before, the clinic-level transformations made to provide care as a Missouri Medicaid Health Home were massively significant. Many of the clinic respondents indicated that the changes and transformations were several to mention (Askelson et al., 2014). Clinics and health centers that had begun towards becoming patient-centered medical home status or were recognized as one also had to make some significant changes (Askelson et al., 2014). One respondent indicated that every medical home was not the same, and every program had varied requirements; as an outcome, there were always a lot of changes and transformations that needed to be implemented. Most of the changes were connected to hiring more staff and changing clinic processes. Most often, respondents commented about hiring health coaches when explaining the need for more staff. A good chunk of the process mentioned modifications or provided during the interviews were wide and often included heightening the scope and use of the electronic medical or health record (Askelson et al., 2014). Generally, process changes included making better use of available data to inform medical care and track referrals and implemented the team-based provision of care.

Changes related to Reducing Emergency Department Use and Hospital Readmissions

Two of the intended results of providing health homes to the higher-risk patients under the Medicaid umbrella were aimed at reducing unnecessary or inappropriate use of the emergency department and hospital readmissions. Some health centers and clinics identified specific changes being implemented to reduce visits to the emergency departments and readmissions into healthcare facilities. However, a significant chunk of the clinics was not advanced enough in the implementation process to have begun working on these areas in a considerably substantial fashion. A considerable number of changes were connected to clinic processes and communication. Limitations and barriers to successful changes were linked to clinics not having more profound relationships with local healthcare systems and hospitals or not having electronic access to records at the institutions mentioned. The health centers and clinics that reported significant progress in making the necessary changes were connected to larger systems of health care. Clinics that have not initiated addressing these challenges mention the lack of a physician on a 24/7 basis. Many of the clinics indicated that it was considered early to tell if these changes would provide efficient and effective on a large scale. Some clinics do not have adequate information about the successes connected to the changes. However, a considerably higher percentage of the efforts aimed at minimizing the rates of Medicaid patients using emergency departments and hospital readmissions are new, and the responding health facilities had concerns about the level to which the information and data related to any changes in these results could be interpreted. Often, though, the responding clinics were capable of relaying patient anecdotes and examples that showed their process and any success stories. For instance, in some clinics, a multidisciplinary team composed of nurses, social workers, the emergency department provides, and physicians were formed to precipitate these changes. Out of these interdisciplinary teams, several patients have been identified. These patients would benefit from the changes being introduced to reduce the use of emergency departments. In some instances, care conferences have been created by clinics and other care facilities where goals are set for the patient. These goals are aimed at improving the condition of the patient.

These changes, however, have significant costs attached. In the study, the respondents were asked to explain if there were any significant costs attached to implementing these changes. The costs mentioned were not just limited to finances (Unützer, Harbin, Schoenbaum & Druss, 2013). Apart from financial costs, the respondents also cited staff education and staff frustration as costs of implemented changes connected to becoming a patient-centered medical home. Staff frustration was commonly mentioned. It is time-consuming to educate Medicaid patients of the need to stay out of emergency departments, and instead contact their primary caregivers. There are a good number of patients who feel like the emergency department offers better care than their primary caregivers, and this requires a lot of staff time and resources to turn around. In some instances, it has been argued that these patients have an ulterior motive to be visiting the emergency department (Unützer, Harbin, Schoenbaum & Druss, 2013). A common motivation mentioned by the respondents is that the patients get some medications that they are otherwise unlikely to get if they visited their primary care providers. The other obstacle mentioned by the respondents is making the clinic team understand the model of health care home. That understanding is not limited to the staff but the whole community. They must understand what resources are available to be used by the clinics in ensuring that patients embrace primary care more than emergency department visits.

Some of the clinics have not addressed the scheduling aspect of ensuring patients access their primary care providers in a good time. Iovan, Lantz, Allan, and Abir (2019) explain that scheduling is vital in providing the patients access to their health care providers in a timely fashion. Some clinics have not addressed the issue of patient scheduling yet, which implies that patient’s access to healthcare providers in good time is compromised. For the clinics improving or making changes to their scheduling process, advanced access to providers and care is developed. In an improved care schedule, patients can call the clinics and receive a same-day appointment, or they can easily schedule more than two days out. In instances of urgent care, walk-in appointments make much more sense than having to make them two days prior. There is no schedule for urgent care. Patients pretty much are aware of the services being provided at the urgent care facilities.

In the course of the interview, respondents were tasked with discussing the roles associated or connected to care coordination, case management, and care management. Care coordination is about helping the patients with scheduling and navigating the health care system through coordination among several healthcare providers. Care management is about helping the patients manage their chronic health conditions through education about home care, adhering to medication, and compliance. Case management, on the other hand, concerns connecting the patients to their community resources like housing resources, public health, dieticians, wellness programs, and several different assistance programs. The clinics reported using a combination of these wordings and other related words like a health coach to encompass a wide range of tasks. Some of the health facilities and clinics had a single individual who covered most of the functions as described under these terms. There was, however, no clear consensus or clarity about which of these mentioned tasks had to be accomplished. Some facilities lacked any person assigned to perform these tasks. It was found common that most of the clinics broke the tasks among several people, especially in the categories of Mas, LPNs or RNs.

Possible Challenges to being a Missouri Medicaid Health Home

A wide range of challenges were identified as being a Missouri Medicaid Health Home. The most common and outstanding problems mentioned included lack of services in the county, patients, lack of access to health records outside of their systems, educating patients and clinical staff, and data from Medicaid and IMPA system for conducting recruitment. The clinics reported that they do not have access to patient data and patient health information outside of their organizational systems. In the event patients receive medical care elsewhere, chances of getting their records if hospitalized and go to emergency records, are challenging to retrieve and use for further primary responsibility for the affected patients.

The other challenge mentioned in the study was the recruitment data. The health facilities and clinics report that the data from the Missouri Medicaid is not easy to use. Because the data is not precise and accurate, the addresses are not neat either. The unclean data makes it extremely challenging to communicate with patients because the addresses provided in the Medicaid data is not accurate. For instance, if a clinic has 2000 people in its Medicaid Health Home, and they try to reach out through email, the information is not likely to be received because some of the information in the systems are not clean and accurate. Education of patients is a challenge, enrolling them in the program is equally a considerable challenge. Patients present the biggest challenge.

In most cases, patients do not follow through with taking the best care of themselves. Financial barriers limit the ability of patients to access specialty physicians. Some of the clinics also report that reaching a specific population demographic has been challenging. For instance, entering the African American population is extremely challenging for some health care facilities. Patient compliance also affects the ability of the programs to be productive and successful.

Findings within and Across Four Regional Cases

The transition to fully becoming a Missouri Medicaid Health Home was found to be less challenging for the clinics that have already meet the levels of patient-centered medical homes. The same observation was made clinics that are currently working to achieve the recognition of PCMH. Clinics that have not implemented PCMH-related changes before signing as Medicaid health homes generally face the pressure of transitioning into this status. Across the clinics, financial, and other resources related to achieving the patient-centered medical home status is a huge challenge.

Given that a considerable number of clinics have implemented massive changes to their existing organizational structures and related cultural practices, a huge component of these changes continues to affect the work of clinical staff. For the most part, it was established that the clinic staff is happy and optimistic about these changes. They are confident that the introduced changes are likely to benefit their patient populations. Respondents also agreed that expanded use of patient data and coordination is beneficial to the program. Several clinics are interested in reducing emergency department visits and readmission into hospitals. Some of the clinics and health centers sampled for the study already have systems in place to address the issue of emergency department visits. Concerning scheduling practices, challenges, and successes, every clinic is uniquely placed. A good number of clinics sampled have already developed and implemented strategies and methods to address the changes to the scheduling practices and needs. However, some of them have not initiated the process. Not all the sampled facilities have designated people in their staff to address tasks linked to coordination of care, management of care, and case management.

Further, a confusion is ripe about what each of the roles listed herein actually entails. Some of the facilities are struggling with accessing data outside of their provider networks and electronic patient database. A lack of access to the information comes with a challenge to patient management and care, as most of the facilities or clinics are unable to fill the void left when patients get treatment at the hospitals or specialty healthcare providers. Recruiting patients into health homes is a challenging aspect of the implementation. A considerably high number of patients fail to understand the concept of rationalization for enrollment into health homes. Clinics are still struggling with the emergency department patient population, a significant percentage of whom face vital socioeconomic barriers to better health and wellness. These considerable barriers present challenges to clinics in the form of consistent communication with the patients, enrolment, and recruitment. A good number of clinics reported that Missouri Medicaid Health Home implementation have an impact beyond that on the targeted population demographic. Clinics understand that including these changes into their organization is likely to have benefits for their expanded population base, not only the ones enrolled under Medicaid. Successes related to the implementation of health homes were evident at the patient, provider, and clinic levels. Clinic personnel reported that some of these changes had improved the effectiveness and efficiency of their service delivery and organizational practices.

Limitations of Qualitative Case Study using Key Informants

Key informant qualitative case studies are in-depth interviews with people who have the knowledge or expertise of the program being evaluated or the subject being studied (Cossham & Johanson, 2019; Garner & Scott, 2013). The purpose of key informant qualitative studies is collecting information from a wide range of individuals- including professionals, expert opinions, community leaders, or residents. The individuals being interviewed must have informed perspectives on the subject under investigation or the aspect of the program being evaluated.

In this study, primary data was collected through qualitative key informant interviews, including local collaborative community partners, regional emergency department administrators, state Medicaid Health Home administrators, and regional Medicaid Health Home administrators. These key informant interviews aimed to describe both the program components and implementation factors that have been essential for bringing down ED super utilization in the Medicaid population.

The critical informant’s qualitative study approach has its limitations and challenges in terms of application (Cossham & Johanson, 2019). The first limitation of this approach is that selecting the right or appropriate vital informants to be involved in the qualitative study is extremely difficult since the people selected may represent diverse viewpoints and backgrounds. In a critical informant qualitative research, the researcher obtains primary data from individuals with different backgrounds and perspectives (Cossham & Johanson, 2019). In such circumstances, the process of selecting the right candidates or participants to be interviewed for the qualitative study may not be as easy as it looks on paper. Without some insider information or knowledge, the researcher may be unable to know the most appropriate people to be used as key informants. Yet, their experience is likely to be limited, which is why they would seek to use such people in the first place.

Alternatively, the key informants may have specific needs that only a set of people can address. This would imply, there is a tension between having the knowledge of enough key informants and selecting key informants to have adequate information (Cossham & Johanson, 2019). Unless the researcher knows the key informants, it may be challenging to determine their expertise, both inappropriateness, and the extent to the program being evaluated or the study under research. Some key informants may be slightly evident because of their roles in a setup or an organization. Again, the researcher may refine his or her understanding of the expertise of the critical informants over time as they continue working with them. The researcher may also make discoveries about the study topic, and therefore his or her understanding of the key informant’s knowledge or expertise may be refined.

Secondly, power imbalance should be avoided, and this is a significant limitation, especially in circumstances when such power is not balanced. The informants may have some level of potential bias or considerable bias without being aware of its existence. The informants may want to present their point of view as absolutely accurate or advocate for an individual approach to the study based on their research strengths or line of thought. Key informants may also have narrow experiences that are not immediately obvious, while self-described and opined leaders may be an isolated advocate with a specialized plan. Just like in the case of participants, there could be social or cultural implications that frame how the key informants interact with the researchers.

While knowledge sharing and distribution is widely accepted as a positive thing in research contexts involving western countries, sharing the knowledge, or giving away information may be prohibited by that culture or group. Some individuals are more easily capable of expressing their understanding and have broader awareness, breadth of perspective, and cultural sensitivity than other people. These considerations are commonly held within any individuals who may be involved in a study and not limited to key informants. Still, it is worth looking at from the perspective of a limitation.

Some key informants are not willing to share their intellectual property, fearful of how such knowledge might be utilized or the consequences of the use. Such key informants may have limited ability to discuss issues openly or may withhold certain information owing to privacy considerations, out of fear, or because they deem such information not necessary or relevant for the study. Such concerns are valid. However, they need to be explained for the researcher to understand and judge their appropriateness or relevance. Such matters may also the person in question less likely to be a key informant. As explained before, key informants must be willing and be transparent to share their knowledge with a lot of openness and transparency (Garner & Scott, 2013). How researchers determine that they are being offered accurate and honest feedback in the form of information is also a considerable challenge, especially if there is a culture of story-telling.

Lastly, there is a considerable potential for the interviewers conducting the key informant interviews to unwittingly influence the feedback or responses offered by the informants (Garner & Scott, 2013). In a critical informant interview setting, the discussions are designed and implemented by the researcher. The researcher asks the key informants the questions and then records the findings as they are observed or heard (Garner & Scott, 2013). However, the researcher may unintentionally or unwittingly influence whatever feedback and responses offered by the informants.

Conclusion

There are two significant reasons behind the push to lower the use of emergency care. Firstly, the emergency department does not provide the best place to get primary care. Super-utilizers often utilize the emergency department for several reasons, apart from having medical emergencies. Some of these reasons include barriers to primary care access, inadequate or lack of insurance, or because their needs are not being addressed. Finding better alternatives to decrease the expensive emergency through better alignment of patients with health care and other services they need should both work towards reducing costs and improving health outcomes. Secondly, health care systems, insurance companies, and emergency departments are continually looking for strategies to enhance the quality of care and lower the use of the most expensive health care services. Further, super-utilizers are a small fraction or percentage of patients, but they account for a considerable proportion of health care expenditures.

There are some critical findings from the studies that should be aimed at reducing the number of emergency department utilization by super-utilizers. Several claims are being made about the strategies and interventions brought forth to lower usage among the super-utilizers, including that they massively reduce the costs and utilization of health care. A significant challenge that has been noticed there have been massively significant methodological challenges with the majority of studies that involve the subject under discussion. A considerable chunk of the studies addressing super-utilizers has established that health care use and associated costs go down the year following the intervention. However, a significant challenge is that the same trend even without any interference. The problem is attributed to the fact that people branded as super-utilizers change somewhat from year to year.